Fkc Mid Sussex County

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 46255 Based on record review, facility document review, staff and patient interview it was determined that facility failed to provide its patients the necessary services outlined in the plan of care. The dialysis center failed to provide the prescribed length of treatment due to short staffing, leaving patients to sign out “Against Medical Advice” (AMA) if unable to stay due to prearranged transportation. (Refer to V463). The cumulative effect of repeatedly shortening treatments resulted in the facility’s inability to protect the patient’s right to individualized and appropriate dialysis. Due to this deficient practice of short staffing resulting in short treatment times, an IJ (Immediate Jeopardy) was called on 11/16/2023 at 10:50 AM. The abatement plan which included closing the Tuesday-Thursday-Saturday shifts, opening the third shift on Monday- Wednesday-Friday, and relocating 13 patients to other local dialysis clinics. The abatement plan was accepted and initiated on 11/16/2023 at 5:25 PM. Immediate Jeopardy was removed on 12/07/2023 at 11:15 AM after evidence that the Tuesday-Thursday-Saturday shifts were closed, the third shift on Monday- Wednesday-Friday was opened, and thirteen patients were relocated to other clinics nearby, and they employed a policy allowing funding for calling a cab to pick up patients who do not wish to wait for rescheduled transportation.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 46255 Based on record review, facility document review, staff and patient interview it was determined that the governing body failed to provide an adequate number of trained staff to deliver dialysis to the patients as ordered, failed to address the inadequate number of staff allowing it to continue over a period of months, leading directly to patients starting treatment late, not receiving their full dialysis treatment, and coerced into leaving AMA so as to have transportation home. Failure to address the perpetual short staffing, allowing dialysis patients to repeatedly fail to receive prescribed treatment, affects the patients health and wellness, ultimately contributing to morbility and mortality. (Refer to TAG 757). Due to this deficient practice of short staffing resulting in short treatment times, an IJ (Immediate Jeopardy) was called on 11/16/2023 at 10:50 AM. The abatement plan which included closing the Tuesday-Thursday-Saturday shifts, opening the third shift on Monday- Wednesday-Friday, and relocating 13 patients to other local dialysis clinics. The abatement plan was accepted and initiated on 11/16/2023 at 5:25 PM. Immediate Jeopardy was removed on 12/07/2023 at 11:15 AM. after evidence that the Tuesday-Thursday-Saturday shifts were closed, the third shift on Monday- Wednesday-Friday was opened and thirteen patients were relocated to other FMC clinics nearby,and they employed a policy allowing funding for them to call a cab to pick up patients that do not wish to wait for rescheduled transportation.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 46255 I. Based on medical record review, policy review, and staff interview, it was determined that for 12 of 22 patients (Patient # 5, # 9, # 10, # 13, # 14, # 15, # 16, # 17, # 18, # 19, # 20, and # 21) in the medical record review sample, the dialysis treatment was shortened with no evidence of physician notification or of a signed AMA [Against Medical Advice] form. Failure to receive the prescribed dose of dialysis may lead to the patient not meeting adequacy goals, affect patient outcomes and morbidity. Findings include: A. Review of facility policy titled “Early Termination or Arriving Late for Treatment” dated 11/07/2022 revealed, “ ...The RN [Registered Nurse] who evaluated the patient must document the rationale for early termination of treatment and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible to notify the physician, and document on the AMA, [Against Medical Advice] form ...Against Medical Advice forms are...Signed with each early termination event and filed in the patient’s medical record... Signed by the patient and witnessed by the Supervising nurse upon completion of the above steps ...”. B. On 9/28/2023 Patient # 5 received 3 hours and 10 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 50 minutes less than ordered. -Employee # 9 entered the following note at 5:01 PM, “UF [Ultrafiltration] off, patient alert, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. C. On 9/28/2023 Patient # 9 received 2 hours and 12 minutes of dialysis. -The prescribed treatment time for the patient was 3 hours and 30 minutes. -The patient’s treatment was 1 hour and 18 minutes less than ordered. -Employee # 1 entered the following note at 4:30 PM, “Denies complaints, patient alert, ended, signed off related to transportation.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. D. On 9/28/2023 Patient # 10 received 3 hours and 22 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours and 15 minutes. -The patient’s treatment was 53 minutes less than ordered. -Employee # 8 entered the following note at 4:22 PM, “Denies complaints, ended.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. E. On 9/28/2023 Patient # 13 received 3 hours and 31 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 29 minutes less than ordered. -Employee # 8 entered the following note at 10:10 AM, “Denies complaints, UF off, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. F. On 9/28/2023 Patient # 14 received 3 hours of dialysis. -The prescribed treatment time for the patient was 3 hours and 30 minutes. -The patient’s treatment was 30 minutes less than ordered. -Employee # 8 entered the following note at 10:24 AM, “Denies complaints, UF off, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. G. On 9/28/2023 Patient # 15 received 2 hours and 45 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 1 hour and 15 minutes less than ordered. -Employee # 1 entered the following note at 4:19 PM, “Denies complaints, UF off, patient alert, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. H. On 9/28/2023 Patient # 16 received 2 hours and 45 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 1 hour and 15 minutes less than ordered. -Employee # 8 entered the following note at 5:01 PM, “Treatment ended.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/17/2023 at 1:43 PM. I. On 9/29/2023 Patient # 17 received 3 hours and 5 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 55 minutes less than ordered. -Employee # 10 entered the following note at 3:19 PM, “Denies complaints, UF off, patient alert, treatment discontinued, without problem...” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/15/2023 at 1:44 PM. J. On 9/29/2023 Patient # 18 received 3 hours and 2 minutes of dialysis. -The prescribed treatment time for the patient was 3 hours and 30 minutes. -The patient’s treatment was 28 minutes less than ordered. -Employee # 8 entered the following note at 10:10 AM, “Denies complaints, UF off, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/15/2023 at 1:45 PM. K. On 11/4/2023 Patient # 19 received 1 hours and 16 minutes of dialysis. -The prescribed treatment time for the patient was 3 hours and 30 minutes. -The patient’s treatment was 2 hours and 14 minutes less than ordered. -Employee # 1 entered the following note at 3:24 PM, “Denies complaints, patient alert, treatment discontinued without problem.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/15/2023 at 11:00 AM. L. On 11/4/2023 Patient # 20 received 2 hours and 58 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 1 hour and 2 minutes less than ordered. -Employee # 11 entered the following note at 10:28 AM, “Denies complaints, UF off, patient alert, treatment discontinued without problem, pt complained of feeling bad and was slow to respond and gagging, blood returned, and treatment ended.” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/15/2023 at 11:02 AM. M. On 11/13/2023 Patient # 21 received 3 hours and 11 minutes of dialysis. -The prescribed treatment time for the patient was 4 hours. -The patient’s treatment was 49 minutes less than ordered. -Employee # 10 entered the following note at 11:03 AM, “Treatment ended, UF off...” -There was no evidence of the patient having signed an AMA form. This finding was confirmed with Employee # 1 on 11/15/2023 at 11:27 AM. II. Based on medical record review, policy review and staff interview, it was determined that for 2 of 7 AMA forms in the medical record review sample, the dialysis treatment was shortened with no evidence of supervising nurse witness signature on the AMA [Against Medical Advice] form and no time of treatment ended for 2 of 7 AMA forms. Failure to receive the. Findings include: Review of facility policy titled “Early Termination or Arriving Late for Treatment” dated 11/07/2022 revealed, AMA [Against Medical Advice] forms are...Signed with each early termination event and filed in the patient’s medical record... signed by the patient and witnessed by the supervising nurse upon completion of the above steps ...”. N. The AMA forms were not complete for Patient #22. The following information was missing: - 8/22/2023 No supervising nurse witness signed the form. -10/13/2023 No supervising nurse witness signed the form. -9/12/2023 The time the treatment ended was not documented on the form. -9/262023 The time the treatment ended was no documented on the form. This finding was confirmed with Employee # 1 on 11/15/2023 at 11:15 AM. O. 17 out of 23 patients are signing off AMA early to make their prearranged transportation times. - 17 of 23 patients cited late start times and transportation as a reason for ending their treatments early on Tuesdays, Thursdays, and Saturdays. - Patients stated to staff as documented on the AMA forms, that they “do not want to wait for transportation”. This finding was confirmed with Employee # 1 on 11/15/2023 at 11:15 AM. Due to this deficient practice of short staffing resulting in short treatment times, an IJ (Immediate Jeopardy) was called on 11/16/2023 at 10:50 AM. The abatement plan which included closing the Tuesday-Thursday-Saturday shifts, opening the third shift on Monday- Wednesday-Friday, and relocating 13 patients to other local dialysis clinics. The abatement plan was accepted and initiated on 11/16/2023 at 5:25 PM. Immediate Jeopardy was removed on 12/07/2023 at 11:15 AM, after evidence that the Tuesday-Thursday-Saturday shifts were closed, the third shift on Monday- Wednesday-Friday was opened and thirteen patients were relocated to other FMC clinics nearby, and they employed a policy allowing funding for them to call a cab to pick up patients that do not wish to wait for rescheduled transportation.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 46255 Based on observation, review of facility documents, Governing Body, and interviews with patients and staff, it was revealed that the facility failed ensure that an adequate number of personnel were present to meet the needs of the patients which can affect patient outcomes and morbidity. Findings include: Facility document staffing and patient seating charts for the following dates revealed the following findings which were confirmed at the time of discovery by Employee #1 on 11/14/2023 at 12:43 PM : Staffing ratio is 1 RN (Registered Nurse) to 12 patients (meds and assessments), 1 CCHT (Certified Clinical Hemodialysis Technician) can take up to 4 patients per shift. For example, for 24 patients the ratio would be 2 RNs and 3 CCHTs. One RN can do assessments, medications and cap-offs for all patients, the other RN can take patient assignment as well assist with meds and assessments if needed. (one RN and one CCHT can take one group of 12 with the other RN helping with put ons, take offs and meds and assessments). The CM helps with put ons and take offs and can assist with patient assignments, meds, or assessments if needed. The RN does all the Medications (Meds) and Assessments and will have to dialyze patients. For a patient census of 37 (all 3 shifts added together), the acceptable ratio is 2 RNs and 3 CCHTs. On 09/28/2023 there was 1 RN (Employee #1) scheduled the full day, 1 RN scheduled to 11:00 AM, and 1 CCHT scheduled 2:00 PM- 5:45 PM -There were 37 patients scheduled with 6 absent = 31 patients. -Acceptable staffing for 31 patients (all shifts added together) is 2 RNs and 3 CCHTs. On 10/28/2023 three staff members called out leaving Employee # 1 the only staff member to open the clinic. -Another staff member Employee # 2 came in an hour or so later to help employee #1 who is the CM (Clinic Manager). -30 patients were originally scheduled. -7 patients had to be diverted to other units for dialysis for lack of staff. -14 patients either left and didn’t return (due to lack of staff) or were no shows, 1 traveler, and a patient whose catheter could not be de-clotted on site. - 8 patients remained to be dialyzed. -The clinic opened late due to lack of staffing. On 11/4/2023 there were 2 RN’s and 1 CCHT scheduled. One of the RN’s was the CM. -28 patients scheduled. - acceptable staffing is 2 RNs and 3 CCHTs -Interview on 11/14/2023 at 08:45 AM with Employee #1 who stated that “staffing has been an issue for several months; governing body is aware, but no immediate changes. The techs do not want to come here from other clinics because the CCHT to patient ratio is high especially if there is 1 nurse and 1 CCHT. We used to have a third shift on Mondays, Wednesdays and Fridays but had to close it due to lack of staffing.” -Interview with Employee #3 on 11/14/2023 at 03:05 PM stated that staffing has been bad for a while. It had been suggested to Governing Body to close the Tuesday -Thursday - Saturday shifts down and open up a third shift on Monday- Wednesday -Friday but it never done.” -Interview with Patient #22 on 11/27/2023 at 11:15 AM who stated, “they are always short of help here nothing ever changes.” Due to this deficient practice of short staffing resulting in short treatment times, an IJ (Immediate Jeopardy) was called on 11/16/2023 at 10:50 AM. The abatement plan which included closing the Tuesday-Thursday-Saturday shifts, opening the third shift on Monday- Wednesday-Friday, and relocating 13 patients to other local dialysis clinics. The abatement plan was accepted and initiated on 11/16/2023 at 5:25 PM. Immediate Jeopardy was removed on 12/07/2023 at 11:15 AM. after evidence that the Tuesday-Thursday-Saturday shifts were closed, the third shift on Monday- Wednesday-Friday was opened and thirteen patients were relocated to other FMC clinics nearby, and they employed a policy allowing funding for them to call a cab to pick up patients who do not wish to wait for rescheduled transportation.”